AKT questions, nMRCGP exam

1. Your practice nurse asks for your advice about a 66-year-old woman with a venous ulcer. Her ankle brachial pressure index (ABPI) is normal. Which one of the following interventions has been shown to increase healing of her ulcer? [Show Discussion]

A. Antibiotics
B. Exposure to air
C. Four-layer compression bandaging
D. Larvae
E. Non-occlusive dressings

Answer: C

four-layer compression bandaging (DOI: 10.1136/bmj.b1344) is a systematic review and meta-analysis of two forms of compression bandages (four-layer bandage and short-stretch bandage) in the treatment of venous leg ulcers. It concludes that the four-layer bandage significantly reduced the time to healing (hazard ratio = 1.31, 95% confidence interval = 1.09 to 1.58). Short-stretch bandages are useful in patients who are mobile and should be replaced daily. Although the four-layer bandage system is effective, its bulkiness may lead to non-adherence in some patients. It is designed to be left in place for several days, so its use is limited in highly exuding ulcers because dressings may need to be changed more often. Therefore, although four-layer bandages may improve healing overall, the choice of compression bandage should reflect the patient’s specific needs and circumstances. Of the other alternatives, antibiotics are of limited value unless there is cellulitis. Dressings are normally occlusive as ulcers heal better in a moist environment. Larvae have been shown to improve debridement (which is possibly an important component of healing) but not healing itself.

2. Your health care assistant asks for your advice on carrying out an ABPI on a patient with leg ulceration. Which one of the following pieces of advice below is appropriate?

A. The ABPI represents the highest recorded systolic pressure recorded in the two arms over the highest recorded systolic pressure in the affected leg
B. The ABPI represents the highest recorded systolic pressure recorded in the affected leg over the systolic pressure in the ipsilateral arm
C. The ABPI represents the highest recorded systolic pressure recorded in the affected leg over the highest recorded systolic pressure in either arm
D. The ABPI represents the highest recorded systolic pressure recorded in the ipsilateral arm over the systolic pressure in the affected leg

Answer: C

ABPI1 = P1/Pa—where ABPI1 represents the ABPI for a leg, P1 represents the highest pressure obtained from the ankle vessels in that leg and Pa is the highest brachial pressure in the two arms

3. Your practice nurse asks for your advice about a female patient of 67 years with severe, weeping varicose eczema that appears to be infected. Along with antibiotics and emollients, which is the single most appropriate management plan? [Show Discussion]

A. Emollients alone
B. Potassium permanganate (1 : 10 000)
C. Topical steroid (weak)
D. Topical steroid (potent)
E. Topical steroid (potent) + potassium permanganate (1 : 10 000)
F. Topical steroid (weak) + potassium permanganate (1 : 10 000)

Answer: E

potent topical steroids are likely to be needed for up to a month before stepping down. Potassium permanganate (1 : 10 000) is useful in moist weeping eczema and in usually prescribed as 'tablets' to be diluted in water (e.g. 'Permitabs'). It is particularly important to be aware that some of these patients have a contact sensitivity to the treatment itself ('MIMS' has a useful table of potential sensitizers in various preparations). Furthermore, these patients will usually require long-term emollients once the acute flare has settled.

4. At a patient group meeting in your practice, there is interest in screening for abdominal aortic aneurysm (AAA) following the tragic demise of the chairman from a ruptured aneurysm. Which one of the following statements is correct?

A. AAA is as common in women as in men
B. Computerized tomography is the screening method of choice
C. The usual threshold for intervention is 7 cm
D. Four percent of men older than 65 years will have an AAA
E. Women are to be screened from 2009 by the NHS

Answer: D

4% of men will have this condition. The NHS screening programme (which is being gradually implemented) is for men older than 65 years in whom the condition is much more common.

5. An 18 month old girl is brought to the surgery by her mother who is concerned regarding her development. On examination, she is able to crawl but is unable to stand unaided. She can hold a book and turn several pages but is not yet able to turn the pages singly. She has a vocabulary of 25 words but is unable to use two or three word phrases.Which is the SINGLE best description of this patient’s development? Select ONE option only.
A. Fine motor delay
B. Global developmental delay
C. Gross motor delay
D. Isolated speech delay
E. Normal development

Answer: C

At 18 months, a child with normal gross motor development will be able to walk well carrying a toy, and be able to walk up and down stairs with help. Building a tower of three cubes or turning pages of a book, two or three at a time would demonstrate normal fine motor development at this age. A child with normal speech development at 18 months will chatter continuously during play and use between six and twenty recognizsable words.Signs of abnormal development at 18 months include inability to stand or walk, no pincer grip, no spontaneous vocalizsation, and inability to recogniszee simple commands.

6. A 6 year old boy attends the community paediatric clinic with his parents. They are concerned that he is currently struggling academically at school. He is reading and writing at a level below that of his 4 year old brother. Cognitive testing reveals an intelligence quotient (IQ) of 54.Which SINGLE description best describes this patient’s intellectual ability? Select ONE option only.

A. Normal intelligence
B. Mild learning disability
C. Moderate learning disability
D. Severe learning disability
E. Profound learning disability

Answer: B

An IQ of 54 is consistent with a mild learning disability (LD).
Normal, >70
Mild LD, 50-–69
Moderate LD, 35-–49
Severe LD, 20-–34
Profound LD, < 20

IQ testing does not assess functional ability and may be affected by communication difficulties. Children with mild LD are often identified after starting school, whilst while those with moderate LD will require significant support at school. Patients with severe LD will often develop simple speech only, and those with profound LD may not develop speech at all

7. An 18 month old girl is brought to the surgery by her parents who are worried that her development has regressed over the last 2 months. She had normal developmental milestones up until the age of 15 months. However, she is now unable to walk and can only crawl. Her first words have become unrecognisable and she is now only able to babble. She has had two seizures in the last month.

A. Asperger’s syndrome
B. Cerebral palsy
C. Conduct disorder
D. Down’s syndrome
E. Dyslexia
F. Fetal alcohol syndrome
G. Fragile X syndrome
H. Gilles de la Tourette syndrome
I. Obsessive compulsive disorder
J. Rett syndrome

Answer: J

Rett syndrome is a sporadic neurodevelopmental syndrome seen almost exclusively in girls aged 17-–18 months. It is characterizsed by developmental regression following a period of normal childhood development. There is a subsequent rapid deterioration in symptoms including seizures and dementia.

8. A 14 year old boy is reviewed in the community paediatric clinic. He has a moderate learning disability. On examination, it is noted that he has a prominent forehead, large ears and large testes. His height and weight are both on the 50th centile for his age.

A. Asperger’s syndrome
B. Cerebral palsy
C. Conduct disorder
D. Down’s syndrome
E. Dyslexia
F. Fetal alcohol syndrome
G. Fragile X syndrome
H. Gilles de la Tourette syndrome
I. Obsessive compulsive disorder
J. Rett syndrome

Answer: G

Fragile X syndrome is characterizsed by developmental delay, mild to moderate learning disability and phenotypical features including long face, prominent forehead, large ears and large jaw. Post-pubertal boys typically have macro-orchidism.